Health Assessment Module 2

Intro to Health Assessment, Obtaining a Health History, Techniques and Equipment for Physical Assessment

Health Assessment

a systemic method of collecting and analyzing data for the purpose of planning patient-centered care

Goals:

• to identify the patient’s strengths, weaknesses, health problems, and deficits

• to develop a plan of care following the ANA Standards of Practice

Components of Health Assessment

Health History, Physical examination, Documentation of data

1. Collect health history

2. Perform physical examination

3. Document data

4. Analyze and interpret data

5. Develop plan of care

Nursing Process Steps

1. Assessment - check vital signs, ask about symptoms, review medical history etc

2. Diagnosis- identify the patients actual or potential health problems

3. Outcome identification- what you expect the outcome or goals of the patient should be through nursing care

4. Planning- set measurable goals and nursing interventions to achieve them

5. Implementation- carry out the planned nursing interventions

6. Evaluation- determine if your plan was achieved and revise the care plan if needed

Health History

Consists of subjective data collected during an interview

Terms

Signs- are objective data observed

Symptoms- are subjective data perceived and reported by the patient

Clinical manifestation- often used to describe the presenting signs and symptoms experienced by a patient

Primary source data- subjective data acquired directly from a patient

Secondary source data- data are acquired from another individual

Physical Examination

collection of objective data, such as vital signs, height, and weight

Documentation of Data

Occurs at the same time of the health care encounter

complete, accurate, and descriptive documentation

Legal permanent record

Serve as a baseline for the the evaluation of subsequent changes and decisions related to care

• Electronic health record (EHR): a digital version of personal health information maintained by health providers over time

Basic principles of documentation: accurate, concise, without bias or opinion and at the point of care

Types of Health Assessments

1. Comprehensive assessment- involves a detailed history and physical examination performed at the onset of care in a primary care setting or on admission to a hospital or long-term care facility

2. Problem-based/focus assessment- involves a history and physical examination that is limited to a specific problem or complaint (walk-in or emergency)

3. Episodic/ follow-up assessment- following up with a health care provider for a previously identified problem

4. Shift assessment- must be done once a shift for hospitalized patients

5. Screening Assessment/examination- disease detection

Physical Assessment skills

Inspection

Palpation

Percussion

Auscultation

Inspection

First step in physical examination

Visual examination of the body

might need equipment to facilitate

Palpation

using hands to feel the texture, size, shape, consistency, pulsation, and location of certain parts of the body

identify areas the patient reports as being tender or painful, gentle touch wirh warm hands and short nails

Explain the purpose, need, manner, and location

Light palpation

• pressing down to a depth of apprx 1cm

• assess skin, pulsations, and tenderness

• before deep palpation

Deep palpation

• pressing down to 4cm with one or both hands

• to determine size and shape of organ

Percussion

to evaluate the size, borders, and consistency of internal organs

to detect tenderness

to determine the extent of fluid in a body cavity

Direct percussion

involves striking a finger or hand directly against the patient’s body

Evaluate sinus by tapping over

Evaluate tenderness or pain over the kidney by striking the CVA directly with a fist

Indirect percussion

tapping on a finger placed on the patient's body to listen to the sounds and check the organs underneath.

Fist and Finger

5 percussion tones

Tympany: heard over the abdomen

Resonance: heard over lung tissue

Hyperresonance: heard over inflated lungs

Dullness: heard over the liver

Flatness: heard over bones and muscle

Auscultation

listening to sounds within the body

with or without stethoscope

Health promotion and health protection

Health Promotion- is behavior motivated by the desire to increase well-being and actualize human health potential

3 levels

• Primary, secondary, tertiary

Health protection- behavior motivated by the desire to actively avoid illness, detect is early, or maintain functioning within its constraints

Primary prevention

focus on protection to prevent occurrence of disease

• immunizations, pollution control, nutrition

Secondary prevention

focus on early identification of disease before it becomes symptomatic to halt the screen progression of the pathologic process

• screening examinations

Tertiary prevention

focus on minimizing severity and disability from disease through appropriate therapy for chronic disease

• diabetes mellitus management

Methods for obtaining a health history

Health history questionnaire, Interview

Interview process

Physical setting

Patient-centered approach

Establishing Rapport